Orders for Medical Care
PROFESSIONAL PRACTICE GUIDELINE
C
ollege
publications
contain
practice
parameters and standards, which should
be considered by all Ontario Respiratory
Therapists in the care of their clients and in the
practice of the profession. College publications
are developed in consultation with professional
practice
leaders
and
describe
current
professional expectations. It is important to
note that these College publications may be
used by the College or other bodies in
determining whether appropriate standards of
practice and professional responsibilities have
been maintained.
COLLEGE
OF
RESPIRATORY ThERAPISTS
JANUARY 2013
OF
ONTARIO
Professional Practice Guideline
table of contents
Introduction
3
Delegation and the ordering of controlled acts - what you need to know
5
When is an order required?
Who can Respiratory Therapists take orders from?
What constitutes a valid order?
What about performing a controlled act in an emergency?
Direct orders
RT Driven Protocols
Table 1: Comparison of Mechanisms for Performance of
Controlled Acts by Non-Authorized Persons
6
7
8
8
8
9
Medical directives
10
The essential elements of a properly constructed medical directive
11
Medical directives and the ordering of controlled acts
Types of Orders
What about an order for medication?
10
11
11
What about an order for a diagnostic test?
12
What about verbal orders?
12
What about an order for mechanical ventilation?
What about re-orders?
What about automatic discontinue orders?
What about orders for individuals from outside Ontario?
What are my responsibilities related to orders?
Glossary
2
4
12
13
13
13
14
15
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ORDERS FOR MEDICAL CARE
INTRODUCTION
Many of the activities undertaken by Respiratory Therapists are initiated
because an order has been given. Various pieces of legislation (e.g.,
Public Hospitals Act, Independent Health Facilities Act, Long Term Care
Act, Laboratory and Specimen Collection Centre Licensing Act) also
have requirements related to orders for medical care. Your employer
may also have policies and procedures related to orders. If legislation
applicable to your practice, or your employer's policies and procedures
are more restrictive than the College's standard of practice, you must
follow the requirements of the legislation and should abide by your
employer's policies and procedures. Where the legislation or your
employer's policies and procedures are more permissive than the
standard of practice of the College, you must adhere to the standard of
practice of the College. This Practice Guideline is intended to provide
you with information about the standard of practice related to orders for
medical care. The College has also developed Professional Practice
Guidelines (PPGs) on the “Interpretation of Authorized Acts”,
“Delegation of Controlled Acts”, and “Documentation” that may have
complementary and/or overlapping information related to orders.
www.crto.on.ca
Did you know...
The RTA was updated
in 2009 to include a 5th
authorized act?
In the course of
engaging in the practice
of respiratory therapy, a
member is authorized,
subject to the terms,
conditions and
limitations imposed on
his or her certificate of
registration, to perform
the following:
1. Performing a
prescribed
procedure below
the dermis.
2. Intubation beyond
the point in the
nasal passages
where they
normally narrow or
beyond the larynx.
3. Suctioning beyond
the point in the
nasal passages
where they
normally narrow or
beyond the larynx.
4. Administering a
substance by
injection or
inhalation.
5. Administering a
prescribed
substance by
inhalation.
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Professional Practice Guideline
Did you know...
The legislated scope of
practice of RTs is:
The practice of respiratory
therapy is the providing of
oxygen therapy, cardiorespiratory equipment
monitoring and the
assessment and treatment
of cardio-respiratory and
associated disorders to
maintain or restore
ventilation.
Take a moment to
consider...
What is your role and scope
of practice where you work?
What is your individual
scope of practice?
WhEN IS AN ORDER REQUIRED?
The Respiratory Therapy Act, 1991 (RTA) requires an order for all
controlled acts authorized to Respiratory Therapists (regardless of practice
setting) except for:
• suctioning beyond the point in the nasal passages where they
normally narrow or beyond the larynx; and
• administering a prescribed substance by inhalation.
If the activity is not a controlled act, it is in the public domain and may not
require an order. The Regulated Health Professions Act (RHPA), 1991 also
provides for exemptions in an emergency (see PPG Interpretation of
Authorized Acts).
Depending on your practice setting, there may be additional legislative
requirements related to orders for medical care. It is your responsibility to
know what the legislative requirements that affect your practice are for
your particular practice setting and you are accountable to abide by these
requirements.
Did you know...
• The Public Hospitals Act requires an order for every treatment or
diagnostic procedure [Public Hospitals Act, O. Reg. 965 s. 24].
• The Independent Health Facilities Act requires an order for all
examinations, tests, consultations, and treatments [Independent
Health Facilities Act, O. Reg. 57/92 s. 10].
In other words, the Public Hospitals Act and the Independent Health Facilities
Act may require an order for an activity that is not a controlled act.
Take a moment to consider…
What other legislation affects the requirements for orders for medical care in
your practice?
• Long Term Care Homes Act?
• Home Care and Community Services Act, 1994?
• Laboratory and Specimen Collection Centre Licensing Act?
4
www.crto.on.ca
ORDERS FOR MEDICAL CARE
Delegation and the ordering of controlled acts - what you need
to know.
• Delegation is the transfer of legal authority to perform a controlled
act to a person not authorized to perform that controlled act.
• Delegation often refers to the transfer of authority to perform
“procedures” involving controlled acts.
• Procedures and/or activities that do not involve controlled acts do not
require delegation, however they may still require orders depending
on the practice setting.
• Delegation is a process.
• There are specific standards of practice related to giving and
receiving delegation for RTs (see PPG Delegation of Controlled
Acts).
While it is permissible to delegate the performance of a procedure
involving a controlled act to a health care provider (regulated or nonregulated) who is not authorized to perform that controlled act, it is not
permissible to delegate the ordering of that procedure involving a
controlled act to someone else.
It is the position of the CRTO that there is no provision in the RHPA to
allow a Physician or any other regulated health care professional to
“delegate” the ordering of a procedure involving a controlled act to another
health care provider (see Position Statement Medical Directives and the
Ordering of Controlled Acts).
www.crto.on.ca
Did you know...
For Respiratory Therapists:
•
•
•
Administering an oral
medication is not a
controlled act and does
not require delegation;
however administering
an oral medication does
require an order or a
prescription in most
practice settings.
Performing spirometry
is not a controlled act
and does not require
delegation, but does
require an order in a
hospital or pulmonary
function testing (PFT)
laboratory.
Performing defibrillation
or allergy testing are
controlled acts not
authorized to
Respiratory Therapists
that require both a
process for delegation
and an order (or
medical directive).
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Professional Practice Guideline
Who can Respiratory Therapists take orders from?
An order for a controlled act authorized to Respiratory Therapists (see
PPG Interpretation of Authorized Acts) must be from one of the four
regulated health care professionals, who is a member of:
•
•
•
•
the College of Physicians and Surgeons of Ontario,
the Royal College of Dental Surgeons of Ontario,
the College of Midwives of Ontario, or
the College of Nurses of Ontario if the Nurse holds a certificate of
registration in the extended class (RN(EC)) otherwise known as
Nurse Practitioner.
You are not permitted to accept orders to perform a controlled act from any
other health professional. Respiratory Therapists must be certain they
have a valid order from a regulated health care professional who is
authorized to order/prescribe, and is acting within his/her scope of
practice, prior to carrying out that order1.
Respiratory Therapists may act upon the request of other healthcare
professionals who are communicating the need to implement a valid
medical directive that includes all of the essential elements, and has been
developed in collaboration with all relevant health care professionals. (See
below and the Position Statement on Medical Directives and the Ordering
of Controlled Acts)2.
1 The practice of other Regulated Health Care Professionals such as Midwives and Nurse Practitioners are
governed by their own legislation and standards of practice. For more information on the practice of these
authorizing practitioners, please visit their respective College websites. A complete list of Health Regulatory
Colleges can be found on the Federation of Health Regulatory Colleges of Ontario’s website.)
2 The Position Statement Medical Directives and the Ordering of Controlled Acts was originally developed
in collaboration with the College of Nurses of Ontario and the College of Physicians and Surgeons of
Ontario in 2003; updated in response to changes to the Public Hospitals Act July 2011; and revised 2012.
6
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ORDERS FOR MEDICAL CARE
WhAT CONSTITUTES A VALID ORDER?
An “order” is the authority to undertake an intervention if the circumstances are
appropriate and, in your professional judgement, it is appropriate to undertake the
intervention. If you receive an order, that in your professional judgement does not have
the best interests of the patient/client in mind, then you must question the order. The
fact that you have received a medical order does not necessarily make the intervention
appropriate. Under this circumstance, you should seek clarification of the order.
Furthermore, you have a professional obligation not to proceed until, in your
professional judgement, it is appropriate to do so. Once you have determined that you
need an order to undertake an activity, you must ensure that it is a valid order. A
prescription is also an order. A valid order or prescription is clearly legible and must
include the following information:
•
•
•
•
when the order is given (includes date and time for critical care facilities);
who the order is for (patient/client identification);
who the prescriber is;
the details of the intervention so that it is clear what is being ordered - details of
the treatment, plan of treatment, diagnostic procedure, etc.;
• when the order is to be carried out; and
• how the order is to be carried out.
You may accept orders that specify that they are to be carried out by a Respiratory
Therapist or orders that do not specify a particular health care professional. Examples
are provided later in this practice guideline. If any elements are missing, it is your
responsibility to obtain the missing information and clarify the order. You must not
proceed until all information is available unless it is an emergency.
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Professional Practice Guideline
WhAT ABOUT PERFORMING A CONTROLLED ACT
IN AN EMERGENCY?
Did you know...
Respiratory Therapist
(RT) - driven Protocols
An RT-driven protocol is a
type of direct order (for a
specific patient) to be
implemented by a
Respiratory Therapist. RTdriven protocols outline the
framework and provide
guidance for Respiratory
Therapists to deliver care
only to the specific
patient/client they are
ordered for.
Respiratory Therapists
performing procedures,
including controlled acts, on
patients/clients as per RTdriven protocols, must
ensure they:
• have the knowledge
skill and judgement
to carry out the
protocol;
• have a valid order
for the protocol; and
• clearly document
that they are
providing respiratory
care procedures “as
per the protocol”.
A Ventilation-Weaning
Protocol is a common
example of an RT-driven
protocol. Such a protocol,
when ordered for a specific
patient, may guide the
Respiratory Therapist in
making decisions and
providing respiratory care
for a mechanically
ventilated patient based on
diagnostic and therapeutic
procedures.
8
According to the RHPA: “An act by a person is not a contravention of
subsection 27(1) if it is done in the course of, (a) rendering first aid or
temporary assistance in an emergency”. Therefore, in an emergency
situation a Respiratory Therapist may perform a controlled act even if the
controlled act is not authorized to Respiratory Therapists, and even if the
Respiratory Therapist does not have delegation or an order.
The term “emergency” is not specifically defined in the RHPA, but clearly
includes circumstances where action is immediately required to prevent
death or serious physical harm.
The Health Care Consent Act, 1996 also supports intervention in
emergencies by removing the usual requirement for consent in most
circumstances. Thus, if a Respiratory Therapist faces an emergency
situation, he or she should not let fear of prosecution for performing a
controlled act hinder his or her response.
The College encourages Respiratory Therapists and their employers
who face emergencies on a regular basis to proactively develop policies
and procedures, guidelines, processes for delegation and medical
directives to help guide their response. These documents may also
serve to provide evidence of competency training and ongoing quality
assurance to support the practice of Respiratory Therapists in emergent
situations.
Direct orders
A direct order is an order or prescription for care written by an individual
prescriber for a particular patient for a specific treatment(s) or
intervention at a specific time.
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ORDERS FOR MEDICAL CARE
TABLE 1: COMPARISON OF MEChANISMS FOR PERFORMANCE OF
CONTROLLED ACTS BY NON-AUThORIZED PERSONS
Direct Orders
Protocols
Valid Order
Valid order, type of direct Valid order.
order.
Written by an
individual
prescriber for a
specific
patient/client
Written by an individual
prescriber for a specific
patient/client.
Written Orders
RT Driven Protocols.
Verbal Orders
Telephone Orders
Patient specific
Approved/authorized by
administrative
committees.
Patient specific
May include more than
one procedure (including
controlled acts) to be
carried out by the
specified health care
provider.
Medical Directives
Standing
Orders
Policies and
Procedures
Not a valid order
Not a valid order.
Inappropriate for
carrying out or
discontinuing
orders for medical
care.
“Written” or “signed off”
by all prescribers who
will ultimately be
accountable for
authorizing the
ordering of the
procedures to be
carried out under the
medical directive by the
specified health care
provider(s).
Must also be
approved/authorized by
administrative
committees.
Range of specified
patients under
specified
circumstances.
Approved/
authorized by
administrative
committees.
Similar patients
with similar
circumstances.
E.g., automatic
discontinue
orders for all
patients after 3
days.
May include decision
trees, for example.
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9
Professional Practice Guideline
Did you know...
The Federation of Health
Regulatory Colleges of
Ontario (FHRCO) has
published an
Interprofessional Guide on
the use of Orders, Medical
Directives and Delegation
for Regulated Health Care
Professionals in Ontario.
This guide provides
templates that can assist
you to construct
Interprofessional Medical
Directives that meet your
standards of practice and
work for your health care
team.
MEDICAL DIRECTIVES
A medical directive is a medical order for a specified range of patients who
meet specific conditions. The medical directive is the order and should
meet the criteria for a valid medical order. This includes the specific
conditions which must be met for the medical directive to apply, a
description of the patients that it applies to, the name and description of the
treatment/intervention being ordered, a list of contraindications, the identity
of the individual(s) who are authorizing the medical directive (e.g., list of
Physicians). The medical directive must also indicate the individual(s) who
are authorized to implement or carry out the order.
MEDICAL DIRECTIVES AND ThE ORDERING OF
CONTROLLED ACTS
It is acceptable for a Respiratory Therapist to act on the communication (in
any form) from a Nurse or any other health care professional of a controlled
act procedure to be done which is based on a medical directive provided
that the Respiratory Therapist does the following:
• Ensures that there was Respiratory Therapy input into the
development of any medical directive that pertains to procedures
performed by Respiratory Therapists.
• Familiarizes himself/herself with the contents of any medical directive
which pertains to procedures being performed by Respiratory
Therapists in their specific practice setting, including confirming that
the individual(s) making the order (i.e. authorizing the medical
directive) is/are authorized to do so under the Respiratory Therapy
Act, 1991 (Physician, Midwife, Dentist or Nurse Practitioner).
• Ensures, prior to performing any procedure that has been ordered
through a medical directive, that the medical directive meets the
criteria for a properly constructed medical directive (see essential
elements of a medical directive below).
• Performs his/her own assessment, comparing the assessment to the
detailed criteria in the medical directive and using his/her own
judgment in deciding to implement the medical directive.
• Ensures that the procedure he/she is about to perform has been
specifically identified in the medical directive as a procedure to be
performed by a Respiratory Therapist.
It is unacceptable for Respiratory Therapists to perform procedures
involving controlled act based upon an order from another health care
provider such as Nurse (RN or RPN) or Physician’s Assistant who is
communicating medical orders (either written or verbal) based on broad,
non-specific, non-collaborative documents or policies that do not include the
essential elements of a medical directive. Organizational policies or
documents that list medications and/or procedures that a Physician’s
Assistant may provide for a group of patients, for example, do not meet the
requirements of a valid medical directive.
10
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ORDERS FOR MEDICAL CARE
ThE ESSENTIAL ELEMENTS OF A PROPERLY CONSTRUCTED
MEDICAL DIRECTIVE INCLUDE:
• The name and description of the procedure, treatment or intervention being
ordered;
• Specific patient/client conditions that must be met before the procedure can be
implemented;
• Circumstances which must exist before the procedure can be implemented;
• Comprehensive list of contraindications to performing the procedure;
• A list of health care professionals who may implement or perform the procedure and
any educational requirements required (for example – only Respiratory Therapists
who work in a certain area and have advanced certification or have completed
continuing education, etc.);
• The health care provider authorizing the medical directive (Physician, Dentist,
Midwife, RN(EC)); and
• A list of administrative approvals from the facility with dates and signatures.
For more information regarding the specific requirements of medical directives see the
CRTO’s Position Statement on Medical Directives and the Ordering of Controlled Acts.
TYPES OF ORDERS
WhAT ABOUT AN ORDER FOR MEDICATION?
A valid medication order requires clear indication of the:
• drug name - either generic or trade name of medication;
• dose - be particularly careful where a drug comes in different dose forms (i.e.,
Flovent ®);
• frequency - (e.g., Q4h, QID). PRN orders should always indicate the maximum
frequency for administration (i.e., Q2h PRN, not just PRN);
• mode of administration - (e.g., oral, inhaled/aerosol, intravenous, intramuscular);
• prescriber - the signature and name of the regulated health professional along with
the appropriate credential (e.g., MD, DDS, RN(EC));
• patient/client's information - the patient/client's name and a second patient identifier
e.g., the date of birth should also be included so that clear identification can be
made;
• date - the date the order was written; and
• time - the time the order was written.
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Professional Practice Guideline
WhAT ABOUT AN ORDER FOR A DIAGNOSTIC TEST?
A requisition may constitute an order for a diagnostic test provided the following
information is on the requisition. A valid order for a diagnostic test requires clear
indication of the:
• prescriber - the signature and name of the regulated health professional along
with the appropriate credential (e.g., MD, DDS, RN(EC));
• patient/client's information - the name, date of birth, health number;
• date - the date the order was written;
• time - the time the order was written;
• test - the procedure required; and
• any specific conditions of test - any specific conditions that are required to be met
or specific questions to be answered by the test.
WhAT ABOUT AN ORDER FOR MEChANICAL VENTILATION?
The application of mechanical ventilation falls under the act of administering a
substance by injection or inhalation (see PPG Interpretation of Authorized Acts).
Specifically, the controlled acts associated with ventilation include the application of
pressurized gas and the administration of oxygen. Minimum requirements for a valid
order consist of:
• prescriber - the signature and name of the regulated health professional along
with the appropriate credential (e.g., MD, DDS);
• patient’s information - the patient’s name – the patient’s date of birth should also
be included so that clear identification can be made;
• date and time;
• direction to initiate mechanical ventilation and oxygen therapy.
Once the need for mechanical ventilation and oxygen therapy are established and there
is a valid order in place, mechanical ventilation and oxygen therapy may be carried out
according to the RT’s scope and standards of practice (knowledge, assessment,
initiation, implementation, evaluation, professional conduct and accountability).
WhAT ABOUT VERBAL ORDERS?
Verbal orders must be transcribed immediately and meet all of the requirements of a
valid order. Verbal orders must be signed by the prescriber or authenticated by another
form of signed paperwork (for example, a Physician can fax an order to authenticate an
order received by phone). RTs are co-accountable to ensuring that they have valid
orders to support their practice and are encouraged to document all communications
regarding the implementing of verbal orders.
12
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ORDERS FOR MEDICAL CARE
(WhAT ABOUT VERBAL ORDERS? continued)
Telephone and verbal orders must be received directly from the prescriber
and not their designate unless the designate is another regulated health
professional (e.g., not secretaries or receptionists). You may wish to have a
verbal or telephone order heard and co-signed by another health care
professional. When transcribing a verbal or telephone order:
• “p.o. prescriber/your name, designation” or “t.o. prescriber/your
name, designation” may be used to indicate that it was a phone or
telephone order, and
• “v.o. prescriber/your name, designation” may be used to indicate that
it was a verbal order.
You may receive a request for booking a diagnostic test from a prescriber's
designate who is not a regulated health professional but you will need to
see the completed order sheet or requisition (by fax, if necessary) to verify
the order before performing the test or procedure.
What about re-orders?
Re-order prescriptions or orders must specify all components of a valid
order (i.e., r/o morphine is not an acceptable re-order prescription).
What about automatic discontinue orders?
Unless the “automatic discontinue” parameters are specified in a medical
directive, you must have an order before you discontinue an intervention.
Policies that automatically discontinue a therapy after a set period of time
are not considered valid orders to discontinue treatments.
What about orders for individuals from outside
Ontario?
Did you know...
The use of verbal
prescriptions (spoken aloud
in person or by telephone)
introduces a number of
variables that can increase
the risk of error. These
variables include:
• Potential for
misinterpretation of
orders because of accent
or pronunciation;
• Sound alike drug names;
• Background noise;
• Unfamiliar terminology;
• Patients having the same
or similar names;
• Potential for errors in
drug dosages (e.g.,
sound alike numbers);
and
• Misinterpretation of
abbreviations*.
Retrieved from Ensuring
Safe and Efficient
Communication of
Medication Prescriptions
(2007) . A joint publication
of the: Alberta College of
Pharmacists (ACP) ,
College and Association of
Registered Nurses of
Alberta (CARNA) , College
of Physicians and Surgeons
of Alberta (CPSA).
As discussed earlier in this guideline, the Respiratory Therapy Act requires
an order for authorized acts to be received from the following regulated
health care professionals in Ontario: Physicians, Dentists, Midwives or
Nurse Practitioners.
A common situation where Respiratory Therapists may be involved with
patients from outside Ontario is when they are asked to replace oxygen
supplies. In and of itself, supplying oxygen is not a controlled act; the
controlled act is administering the oxygen. In most cases, the request for
oxygen is to supply replacement tanks or to fill cryogenic systems, and an
order is not required for this. Some Respiratory Therapists do ask to see a
copy of the original order and most patients carry it with them. If you are
being asked to initiate a therapy, then you need to ensure that you have a
valid order within Ontario.
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13
Professional Practice Guideline
What are my responsibilities related to orders?
As a Member of the CRTO, you are always held accountable for your actions. You must
know where the authority is for you to undertake any activity that requires an order
comes from. At some time you may have to prove that you had the authority to perform
an activity. For your own protection, ensure that the order (or medical directive) you are
acting upon is a valid one. If you are acting upon the authority of a medical directive, be
sure that you know the contents of that medical directive.
Whether you are implementing direct orders or medical directives, you must ensure that
you:
• are acting within the scope of Respiratory Therapy, the role and scope of where
you work and your personal scope of practice;
• are authorized to perform the procedures (subject to terms, conditions and
limitations on your certificate of registration);
• have the knowledge, skills and judgement to perform the procedure competently;
• only implement orders/medical directives that are in the best interest of the
patient/client;
• document where you obtained the authority and what you did (e.g., signing off
your orders, charting “as per protocol” or “as per medical directive”); and
• ensure that you meet the standards of practice of the College and profession in
performing the procedure.
If you receive an order for an intervention that, in your professional judgement is not in
the best interests of the patient/client, then you must question the wisdom of such an
order. If, after discussion with the authorizer issuing the order you are still convinced
that carrying out such an order would be detrimental to the care and safety of the
patient, then you must refuse to implement the order and document all details related to
your decision. (see PPG Documentation).
14
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ORDERS FOR MEDICAL CARE
GLOSSARY
authorized act
College
A controlled act, or portion of a controlled act, that is authorized within a health
profession Act for a health professional to perform [there are five acts
authorized to Respiratory Therapists by the Respiratory Therapy Act, that are
created from 3 controlled acts defined in the RHPA].
College of Respiratory Therapists of Ontario
CRTO
College of Respiratory Therapists of Ontario
emergency
When the person for whom the treatment is proposed is apparently
experiencing severe suffering or is at risk, if the treatment is not administered
promptly, of sustaining serious bodily harm (ref. HCCA).
patient/client
For the purposes of this practice guideline, patient/client denotes a broader
concept than the traditional patient or client receiving direct clinical care, and
includes students, research subjects and sales clients.
plan of treatment
treatment
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A plan that:
• is developed by one or more health practitioners,
• deals with one or more health problems that an individual has, and may
deal with one or more problems an individual is likely to have in the future
given their current health, and
• allows for administration of various treatments or courses of treatment.
Anything that is done for a therapeutic, preventative, palliative, diagnostic,
cosmetic or other health-related purpose, and includes a course of treatment or
plan of treatment, but does NOT include:
• assessment of a person's capacity,
• assessment or examination to determine the general nature of an
individual's condition,
• taking a health history,
• communicating an assessment or diagnosis,
• admission to a hospital or other facility,
• a personal assistance service, and
• a treatment that, in the circumstances, poses little or no risk of harm.
15
College of Respiratory Therapists of Ontario
Ordre des thérapeutes respiratoires de l’Ontario
Phone
Toll Free
Fax
E-mail
(416) 591-7800
1 (800) 261-0528
(416) 591-7890
questions@crto.on.ca
November 2004
Revised February 2006, July 2011 and January 2013
This practice Guideline will be updated as new evidence emerges or as
practice evolves. Comments on this practice guideline are welcome and
should be addressed to:
Professional Practice Advisor
College of Respiratory Therapists of Ontario
180 Dundas Street West, Suite 2103
Toronto, Ontario
M5G 1Z8
Tel (416) 591 7800
Fax (416) 591-7890
Toll Free 1-800-261-0528
E-mail questions@crto.on.ca
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